Monitoring nurturing care environments for early childhood from the national to the municipal level

Key messages There is a dearth of indicators and management information systems to assess early childhood nurturing care environments. The Brazilian Early Childhood Care Friendly Municipal Index (IMAPI) is a robust tool to assess nurturing care environments at the local level. IMAPI was able to detect nurturing care inequities within and across regions. Further validation work is needed to confirm the utility of IMAPI for policymaking.

The Global Nurturing Care Framework developed from the 2016 Lancet Early Childhood Development Series (Black et al., 2017;Britto et al., 2017;Richter et al., 2017) indicates that children need five interrelated and indivisible care domains to reach their full potential.
These are Good Health, Adequate Nutrition, Opportunities for Early Learning, Security and Safety, and Responsive Caregiving. Nurturing care begins since gestation and continues throughout the life course (Black et al., 2021). In 2018, the World Health Organization (WHO) and UNICEF adopted the Nurturing Care Framework (World Health Organization et al., 2018) as an evidence-based road map for countries to follow to implement effective integrated Early Childhood Development (ECD) Programmes. However, efficient monitoring and evaluation of nurturing care environments (i.e., Good Health, Adequate Nutrition, Opportunities for Early Learning, Security and Safety, and Responsive Caregiving), are key for countries to be able to properly implement the Nurturing Care Framework and attain of the Sustainable Development Goals (SDGs) are strongly needed (Black et al., 2017;Britto et al., 2017;Richter et al., 2017;World Health Organization et al., 2018). Although previous efforts have attempted to develop such systems at the national and to some extent the regional or provincial level, this had not been previously attempted at the municipal level (Pedroso et al., 2021). This article introduces the supplement "Development and Application of the Brazilian Early Childhood Care Friendly Municipal Index" by summarising the history, methods, and applications of the Brazilian Early Childhood Care Friendly Municipal Index (IMAPI), and making recommendations on the way forward.
The IMAPI was developed following an 8-step methodology. The first article of this supplement (Buccini et al., 2021a) describes the first three steps involved of an innovative participatory multisectoral decision-making process to identify indicators across the five domains of the Nurturing Care Framework. The IMAPI indicators were selected following four distinct activities conducted with the IMAPI team, technical stakeholders, and experts (Buccini et al., 2021a).
Detail on participants' institutions is described in Table S1. First, indicators across Nurturing Care Framework domains were identified through a comprehensive literature review conducted by the IMAPI team that included investigators who collectively had expertise in epidemiology, maternal-child nutrition, implementation science and data science, and machine learning, including the co-authors of this

Key messages
• There is a dearth of indicators and management information systems to assess early childhood nurturing care environments.

• The Brazilian Early Childhood Care Friendly Municipal
Index (IMAPI) is a robust tool to assess nurturing care environments at the local level.
• IMAPI was able to detect nurturing care inequities within and across regions.
• Further validation work is needed to confirm the utility of IMAPI for policymaking.
ECD-related programmes and services, and Result reflects the effectiveness of ECD-related programmes and services.
Out of 28 common nurturing care IMAPI indicators across IMAPI-M and IMAPI-D, the following four were prioritised in both analyses: "Coverage of information on child nutritional status" (Adequate nutrition, Supportive Services, Coverage), "Coverage of daycare and preschool" (Opportunities for early learning, Supportive Services, Coverage), "Number of students per preschool professional" (Opportunities for early learning, Caregivers' capabilities, Quality), and "Visits by national home-visiting parenting skills programme" (Responsive caregiving, Enabling policies, Effort surveys. This information, together, could make it possible to assess the influence of multiple factors on nurturing care and how it impacts ECD in Brazil, from the national to the municipal level. Second, qualitative research is needed to understand if an IMAPI driven qulaity assurance process could help improve nurturing care program coverage and quality at the municipal level. This approach has been followed with a breastfeeding decision making toolbox analogous to IMAPI but only at the national level Hromi-Fiedler et al., 2019;Pérez-Escamilla et al., 2018). For this reason, dmeonstrating how decision-making at the municipal level can be improved when linked to an IMAPI monitoring system would be truly groundbreaking.

ACKNOWLEDGMENTS
This study was funded by the Bill and Melinda Gates Foundation#